活体供肾肾移植的血管应用解剖

• 综 述 •

活体供肾肾移植的血管应用解剖

张际青张小东

【摘 要】目的 总结活体供肾肾移植供受体的有关血管解剖。 方法查阅近年有关亲属移植供受体血管解剖的国内外文献，并进行综述。 结果 供受体血管解剖对病例选择、手术方案制定及远期效果均有重要作用。供体过早分支和副肾动脉的存在常会影响手术侧、手术方式和吻合方式的选择，其损伤出血及静脉出血均是导致腹腔镜手术转开放手术的重要原因。随着腹腔镜供肾切除的增多，术前准确肾静脉评估也越来越得到重视。多层螺旋CT可代替常规影像学检查并能准确评估供肾血管、血管变异、肾病变、集合系统和其他相关解剖信息。 结论详细了解供受体的肾血管解剖不仅利于手术成功，还能促进活体供肾肾移植的发展。多层螺旋CT已成为供体术前首选“一站式”影像学检查方法。

【关键词】活体供肾受体 肾移植血管解剖多层螺旋CT

中图分类号：R322.12 R699.2 文献标志码：A

VASCULAR ANATOMY OF DONOR AND RECIPIENT IN LIVING KIDNEY TRANSPLANTATION/ZHANG Jiqing, ZHANG Xiaodong. Department of Urology, Beijing Chaoyang Hospital Affi liated to Capital Medicine University, Beijing, 100020, P.R.China. Corresponding author: ZHANG Xiaodong, E-mail: zxd581@

【Abstract】Objective To review the vascular anatomy of the donor and the recipient for the living kidney transplantation. Methods The recent literature about the vessels of donor and recipient in clinical applications was extensively reviewed. Results The pertinent vascular anatomy of the donor and recipient was essential for the screening of the proper candidates, surgical planning and long-term outcome. Early branching and accessory renal artery of the donor were particularly important to deciding the side of nephrectomy, surgical technique and anastomosing pattern, and their injuries were the most frequent factor of the conversion from laparoscopic to open surgery. With increase of laparoscopic nephrectomy in donors, accurate venous anatomy was paid more and more attention to because venous bleeding could also lead to conversion to open nephrectomy. Multidetector CT (MDCT) could supplant the conventional excretory urography and renal catheter angiography and could accurately depict the donors’ vessels, vascular variations. In addition, MDCT can excellently evaluate the status of donor kidney, collecting system and other pertinent anatomy details. Conclusion Accurate master of related vascular anatomy can faciliate operation plan and success of operation and can contribute to the rapid development of living donor kidney transplantation. MDCT has become the choice of preoperative one-stop image assessment for living renal donors.

【Key words】 Living renal donor Recipient Renal transplantation Vascular anatomy Multidetector CT

活体供肾较尸体供肾具有明显的存活优势，腹腔镜等微创手术的发展也促进了活体供肾移植的发展[1-2]。供受体的血管解剖是肾移植手术的基础，全面了解相关血管解剖对供受体的筛选、手术方案制定及避免供受体并发症等方面均有重要作用。

1受体血管解剖

1.1髂内动脉

髂内动脉在骶髂关节处起于髂总动脉，为盆腔脏器和臀部肌肉主要血供。国人普通髂内动脉长

作者单位：首都医科大学附属北京朝阳医院泌尿外科（北京，100020）

通讯作者：张小东，教授，博士导师，研究方向：肾移植、泌尿系肿瘤，E-mail: zxd581@

3.5～

4.5 cm，最长达8 cm，最短仅2 cm[3]。尸体解剖发现：左右髂内动脉终管径分别为（7.84 ± 0.35）m m 及（7.60 ± 0.22）mm，左右肾动脉起始管径分别为（7.32 ± 0.25）mm及（7.21 ± 0.20）mm，两者口径较匹配，为比较理想的吻合动脉[4]。肾动脉与髂内动脉端端吻合可能更符合血液流变学规律，可以获得相对较高的肾灌注压。郑克立[5]报道供肾动脉与受体髂内动脉吻合者，收缩压应不低于15 kPa，而与髂外动脉吻合者则必须高于20 kPa，肾脏才能泌尿。

结扎髂内动脉后对机体的影响：一侧髂内动脉结扎后可通过多个侧支循环建立血供，如腰动脉与髂腰动脉吻合、髂中动脉与骶外侧动脉吻合、痔上动脉与痔中动脉吻合、结扎侧动脉各支与对侧各同名脏支吻合等[3，6]。再次移植时结扎另一侧髂内动脉，盆腔脏器血流会暂时性减少，约2个月后会重建侧支循环，不会造